Provider Demographics
NPI:1265622690
Name:RUTHERFORD, DEE WAYNE (LAT)
Entity type:Individual
Prefix:
First Name:DEE
Middle Name:WAYNE
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 62ND DR
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-5115
Mailing Address - Country:US
Mailing Address - Phone:806-766-0705
Mailing Address - Fax:806-766-0509
Practice Address - Street 1:3211 47TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-4112
Practice Address - Country:US
Practice Address - Phone:806-766-0705
Practice Address - Fax:806-766-0509
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT09692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX22OtherPROVIDER